JMIRx Med Mbwogge et al

Original Paper

Waiting Time and Patient Satisfaction in a Subspecialty Eye

Hospital Using a Mobile Data Collection Kit: Pre-Post Quality
Improvement Intervention

Mathew Mbwogge1, MSc; Nicholas Astbury1, PhD; Henry Ebong Nkumbe2, MD; Catey Bunce3, DSc; Covadonga
Bascaran1, MD
1
International Center for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
2
Africa Eye Foundation Cameroon, Yaoundé, Cameroon
3
Research Data & Statistics Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom

Corresponding Author:
Mathew Mbwogge, MSc
International Center for Eye Health
London School of Hygiene & Tropical Medicine
Keppel Street
London, WC1E 7HT
United Kingdom
Phone: 44 07424409211
Email: m.mbwoge@gmail.com

Related Articles:
Preprint: https://preprints.jmir.org/preprint/34263
Peer-Review Report by Alexandros Argriadis (Reviewer T): https://med.jmirx.org/2022/3/e40444/
Peer-Review Report by Haleh Ayatollahi (Reviewer BK): https://med.jmirx.org/2022/3/e40448/
Peer-Review Report by Anonymous: https://med.jmirx.org/2022/3/e40574/
Authors' Response to Peer-Review Reports: https://med.jmirx.org/2022/3/e40453/

Abstract
Background: Waiting time can considerably increase the cost to both the clinic and the patient and be a major predictor of the
satisfaction of eye care users. Efficient management of waiting time remains as a challenge in hospitals. Waiting time management
will become even more crucial in the postpandemic era. A key consideration when improving waiting time is the involvement
of eye care users. This study aimed at improving patient waiting time and satisfaction through the use of Plan-Do-Study-Act
(PDSA) quality improvement cycles.
Objective: The objectives of this study were to determine the waiting time and patient satisfaction, measure the association
between waiting time and patient satisfaction, and determine the effectiveness of the PDSA model in improving waiting time and
satisfaction.
Methods: This was a pre-post quality improvement study among patients aged 19 to 80 years, who are consulting with the
Magrabi International Council of Ophthalmology Cameroon Eye Institute. We used PDSA cycles to conduct improvement audits
of waiting time and satisfaction over 6 weeks. A data collection app known as Open Data Kit (Get ODK Inc) was used for real-time
tracking of waiting, service, and idling times at each service point. Participants were also asked whether they were satisfied with
the waiting time at the point of exit. Data from 51% (25/49) preintervention participants and 49% (24/49) postintervention
participants were analyzed using Stata 14 at .05 significance level. An unpaired 2-tailed t test was used to assess the statistical
significance of the observed differences in times before and after the intervention. Logistic regression was used to examine the
association between satisfaction and waiting time.
Results: In total, 49 participants were recruited with mean age of 49 (SD 15.7) years. The preintervention mean waiting, service,
and idling times were 450 (SD 96.6), 112 (SD 47), and 338 (SD 98.1) minutes, respectively. There was no significant association
between patient waiting time and satisfaction (odds ratio 1, 95% CI 0.99-1; P=.37; χ23=0.4). The use of PDSA led to 15% (66
minutes/450 minutes) improvement in waiting time (t47=2; P=.05) and nonsignificant increase in patient satisfaction from 32%
(8/25) to 33% (8/24; z=0.1; P=.92).

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Conclusions: Use of PDSA led to a borderline statistically significant reduction of 66 minutes in waiting time over 6 weeks
and an insignificant improvement in satisfaction, suggesting that quality improvement efforts at the clinic have to be made over
a considerable period to be able to produce significant changes. The study provides a good basis for standardizing the cycle
(consultation) time at the clinic. We recommend shortening the patient pathway and implementing other measures including a
phasic appointment system, automated patient time monitoring, robust ticketing, patient pathway supervision, standard triaging,
task shifting, physician consultation planning, patient education, and additional registration staff.

(JMIRx Med 2022;3(3):e34263) doi: 10.2196/34263

KEYWORDS
waiting time; waiting list; patient satisfaction; quality improvement; clinical audit; ophthalmology; patient-centered care

appointment [19]. In low-income economies such as Cameroon,

Introduction waiting time is the time a patient spends at the clinic to obtain
Background a complete health check [20].

Long waiting time can significantly increase costs and be a
major determinant of the satisfaction of those seeking health
care services [1]. Patient experience and satisfaction are closely
linked to the quality of care that users attribute to health care
[2,3]. Although quality of care does not necessarily translate
into patient satisfaction, it can be a major predictor [4]. Patient
experience and satisfaction can also be dependent on the time
patients spend in clinics during their consultation [5]. The
reduction of waiting time has been a key concern, especially
for ambulatory hospitals, owing to increasing outpatient
demands [6]. Efficient management of patient flow in hospitals
ensures high quality of care [7]. It has been reported that patient
flow management as part of a hospital quality improvement
strategy warrants continuous attention and should involve all
staff [7]. Evidence suggests that there is a strong negative
correlation between waiting time and patient satisfaction [8,9].
User dissatisfaction has been strongly linked to waiting times,
with users spending more time in waiting than being attended
to [10]. It is believed that the routine task of health care staff is
to perform their work and improve it [11]. However, the ability
to reduce waiting time and improve services may be limited by
service capacity [12].
In ophthalmology, long waiting time and the dissatisfaction of
those seeking eye care have been worsened by the COVID-19
pandemic [13]. Apart from affecting patient satisfaction, system
delays also affect health care program delivery [14]. Waiting
time has been identified as one of the major challenges in
managing workflow in eye hospitals because of the growing
number of those in need of eye care [15].
Between 2010 and 2019, the number of people with blindness
increased by 10.8% (95% unit interval 8.9%-12.4%) and
moderate to severe visual impairment increased by 31.5% (95%
unit interval 30%-33.1%) [16]. Sub-Saharan Africa faces severe
limitations for well-trained eye care personnel [17]. In
Cameroon, it is estimated that 250,000 people are blind and
600,000 are visually impaired. The prevalence of blindness in
Cameroon is one of the highest in the world, and there is no
government health budget allocation specific to eye health [18].
Hospital waiting time is a major concern in Cameroon as in
many other countries [21]. The current evidence regarding
quality improvement specific to waiting time in hospitals in
Cameroon is lacking [22]. The problem of long waiting times
in clinics in Cameroon can primarily be attributed to poor
management [23], and there is strong evidence that waiting time
in Cameroonian hospitals is the main cause of dissatisfaction
when accessing health care [24]. Its understanding will help in
defining the measures of change needed for its improvement.
The problem of long waiting times at the Magrabi International
Council of Ophthalmology Cameroon Eye Institute (MICEI)
escalated owing to the increase in patient volume. Conscious
of the need to deliver high-quality eye care services, the eye
institute capped its daily patient visits, in part, to deal with the
overwhelming number of patient complaints about waiting time.
Following this, MICEI management sought to investigate the
time that patients spend at the clinic and propose measures of
improvement.
Study Rationale
Our choice of Cameroon stems from the fact that apart from the
lack of any previous study that primarily sought to improve
waiting time and satisfaction in Cameroon, waiting time was
found to be the main reason for patient complaints at the newly
established eye hospital (MICEI) in Cameroon. The study was
the first of its kind that was specific to ophthalmology in
Cameroon. However, we found quality improvement
interventions undertaken in other health areas [22,25,26]. One
sought to improve waiting time by means of hospital-wide
quality improvement, using the Strengthening Laboratory
Management Toward Accreditation model [22]; another sought
to improve early infant diagnoses coverage, timely return of
HIV test results, and initiation of antiretroviral treatment using
the Quality Improvement Collaborative approach [25]; and
another sought to improve the adherence and cure of patients
with tuberculosis, by using SMS text message reminders [26].
We also found 2 studies [23,24] that aimed at investigating
patients’ satisfaction with the quality of health services [23]
and the undertaking of antiretroviral treatment [24].

The concept of waiting time presents different meanings in This study was based on the model of Plan-Do-Study-Act
different contexts. In countries with a regularized appointment (PDSA) [27]. This 4-stage model was proposed by Deming as
system such as the United Kingdom, it is the time spent from a simple way to undertake quality improvement interventions
booking an appointment to when the person attends the in health care. It involves making continuous cyclical

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improvements geared toward achieving what works best for
care users.
The use of pre-post quasi-experimental designs [28,29] and the
PDSA model in health care [30] in general and in ophthalmology
[31] in particular, has been widely reported. A similar study
was conducted in Ethiopia using an appointment system [20].
In addition, there is evidence of use of the Open Data Kit (ODK)
developed by Get ODK Inc, in health care projects in Cameroon
[32].
Specific Objectives
This study had three objectives: (1) determine the waiting time
and satisfaction, (2) measure the association between waiting
time and satisfaction, and (3) measure the effectiveness of the
PDSA model in improving waiting times and satisfaction.
Methods
Study Setting
This study was conducted at the MICEI from June 15, 2018, to
July 28, 2018. MICEI is a subspecialty eye hospital and training
center, with an average of 300 daily outpatient visits [33]. The
center is the only tertiary eye institute in Cameroon, with 72-bed
capacity, 8 ophthalmologists, 8 ophthalmic nurses, and
approximately 70 full-time staff.
Contextual Factors
Study feasibility was carefully examined by assessing some
contextual factors that are likely to affect success [34]. The
Figure 1. Plan-Do-Study-Act conceptual framework. Licensed under the Open Government License. MICEI: Magrabi International Council of
Ophthalmology Cameroon Eye Institute; QI: quality improvement.
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study was made context-specific by using the Model for
Understanding Success in Quality [35]. We calculated the Model
for Understanding Success in Quality score using an Excel
template developed by the East London National Health Service
Foundation Trust [36], as shown in Table S1 in Multimedia
Appendix 1.
The eye care center is suburban, 25 km away from the city center
of the country’s capital. The Center Region is host to 8 other
eye clinics delivering general ophthalmology services in public
and private hospitals. Enabling factors include motivated
executive toward quality improvement, well-structured
microsystem with state-of-the-art equipment, the institute’s aim
to become a center of excellence, and high donor expectations.
In addition, MICEI runs a patient-based and tiered pricing model
similar to that of the Aravind Eye Care System in India, which
is different from the disintegrated hospital-based eye care
delivery within Cameroon. Other positive factors were the
availability of stationery and printing of study materials at the
hospital and the hospitality of the staff.
PDSA—Plan and Do Phase: Intervention
Overview
This was a 2-step person-centered quality improvement
intervention using the PDSA model. The first step involved
situation analysis of the waiting time and mapping of the patient
flow. On the basis of this analysis, best-fit measures were
introduced to offset delays in the waiting time. Figure 1 shows
an adapted PDSA conceptual framework of the intervention
[37].
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Recruitment of Participants
Study participants were recruited from patients consulting with
the MICEI between June 2018 and July 2018, using
nonprobabilistic sampling [38]. Participants were randomly
approached at the point of entry by 2 trained data collectors and
introduced to the study if they met the inclusion criteria, and
only those who voluntarily consented were enrolled. The
inclusion criteria were the following: aged between 18 to 80
years, seeking ophthalmic consultation, and able to understand
and speak either English or French. The exclusion criteria were
the following: incapacity to provide consent; surgical and
postoperative appointments; and patients not following the
normal flow, such as those in the fast track and very important
person categories.
Data Management
Data collection was performed using ODK [39]. A data form
was built using Microsoft Excel 2010 and validated using the
web-based Microsoft Excel Spreadsheet Form (XLSForm Online
version 1.2.0). Then, the Excel data form was converted to a
version (XML) compatible with the server (ODK back end)
using the downloadable Microsoft Excel Spreadsheet Form
(ODK-XLSForm Offline version 1.6.0; Multimedia Appendix
2) and uploaded to ODK Aggregate server (open-source Java
server) with a personalized user ID and password. As this study
was conducted in a predominantly French-speaking region, all
data forms and patient information materials were translated
into French to suit participants.
Huawei MediaPad T2 10.0 Pro and Samsung Galaxy Note 10.1
android tablets with installed ODK Collect application (open
source) for requesting data forms from the server were used to
collect real-time data on waiting time and patient satisfaction.
To check for completeness, 2 dry runs were performed and the
data form was modified before the start of the intervention. Data
collection was automated, thereby reducing errors. The data
form was built such that each question must be answered before
proceeding to the next. All the filled data forms were verified
by the principal investigator for completeness before submitting
to the server.
The latest version of ODK Briefcase downloaded and installed
on Windows 10 was used to extract the data set from the
Aggregate server. Then, this was exported as a CSV file and
loaded into Stata 14 for analysis.
Quality Improvement Team
A quality improvement team was set up, including the principal
investigator, pediatric ophthalmologist, medical records officer,
senior outpatient nurse, head of investigations, nurse assistant,
optical technician, and facility manager. The team met once
every week on less busy days from 7 to 8 AM, to provide
feedback on daily challenges and propose solutions. The team
aimed to reduce waiting time by 25%.
Data Collectors
A total of two data collectors (an advanced-level holder and a
university student) purposely recruited for the study were trained
using a standard operating procedures manual developed for
the study.
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Dry Run and Testing
After 2-day training, a dry run was performed on 2 consenting
patient volunteers. On the basis of the challenges, the data form
was modified to account for interunit counterreferrals (owing
to back-and-forth movements) and include the option, other, to
some of the questions to make answers more flexible. The
questionnaire was finalized after a second dry run, converted,
and resubmitted to the server.
Changes Proposed
The patient flow was mapped, and all consultation rooms were
identified according to room numbers. Patient flow bottlenecks
were identified through brainstorming and direct observations.
On the basis of an interim analysis of data collected from 51%
(25/49) of the participants, the following measures were
proposed to potentially reduce waiting time:
1. A time monitor sheet to record the start and finish times at
each service point.
2. Introduce a second receptionist for the separate handling
of reviews.
3. Introduce a numbering system for all patients (reviews and
new patients alike).
4. Regularly supervise the patient flow for on-the-spot
handling of bottlenecks.
5. Appoint an experienced ophthalmic nurse for effective
triaging of patient files.
6. Educate patients on patient flow, for orientation and
reduction of turnaround time.
7. Standardize waiting time by defining the duration for a full
consultation.
8. A phasic appointment system that includes associating a
nurse assistant to each ophthalmologist, to take notes and
book appointments, and the proactive sorting of patient
files a day before the booked appointments. Each day is
divided into slots corresponding to the maximum number
of patients a physician is able to handle.
9. Grant ophthalmic nurses’ permission to discharge less
complicated cases.
10. Color zoning of the general ophthalmology department to
know who is waiting for whom.
PDSA: Study of the Intervention Phase
Approach to Impact Assessment
A PDSA-led pre-post quasi-experimental design was used to
measure the effectiveness of the intervention, from June 15,
2018, to July 28, 2018. This method was particularly important
because we wanted to address two key aspects of quality:
clinical effectiveness through waiting time and patient
experience through patient satisfaction [40]. We used the
before-after design [29] to keep the intervention as close to
reality as possible. Moreover, it was not ethical to conduct a
pre-post study with a control group as this was a single-center
study [29]. In addition, evidence on the use of PDSA in quality
improvement interventions has been well documented [41-43]
Attributing Results to the Intervention
A total of 49 participants from randomly arriving patients at the
eye institute were invited to participate in a time-motion and
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satisfaction survey at 2 time points (n=25, 51% participants
before the intervention and n=24, 49% participants after the
intervention). Data collectors randomly approached participants
at the point of entry, explained the study to them, and enrolled
only those who provided voluntary consent. Through a process
of shadowing, data collectors recorded the time spent at each
service point, from entry to exit. At the exit, patients were asked
whether they were satisfied and the reasons for their
dissatisfaction, if relevant. We determined that the results were
owing to the intervention by assessing and comparing the
waiting time and patient satisfaction of the 2 samples.
Measures
Processes and Outcomes
The duration of a full consultation day was investigated using
waiting time as the primary outcome variable. Waiting time
was defined as the time spent in the microsystem, from entry
to exit [20]. It was a continuous variable made up of (1) service
time, which is the time the patient is being served and in contact
with staff, and (2) idling time, which is the time the patient
spends between service points, waiting to be served. The
secondary outcome variable was patient satisfaction, defined
as the patient-reported satisfaction with waiting time and service.
This was used to determine whether waiting time was a good
determinant of patients’ satisfaction. Other variables included
participants’ sociodemographic variables.
Assessment of Contextual Factors
Direct observations, quality improvement meeting sessions, and
interim analysis, including the use of data visualization
techniques (scatter and box plots), were used to determine any
unusual data points that can be attributed to contextual factors.
Abnormal data points were identified by calculating the lower
(Q1–1.5[Q3–Q1]) and upper (Q3+1.5[Q3–Q1]) fences. Data
points that fell outside these limits were investigated further.
Data Analysis
Waiting Time and Satisfaction
All statistical analyses were performed using Stata 14 at .05
significance level. On the basis of our sample size, the
Shapiro-Wilk test for the pretest sample (z=1; P=.10) and the
posttest sample (z=−0.98; P=.80) showed that both samples
were assumed to be drawn from a normal distribution [44]. In
addition, the skewness and kurtosis tests for the first sample
(skewness: P=.30; kurtosis: P=.90) and the second sample
(skewness: P=.50; kurtosis: P=.80) fulfilled the normality
hypothesis. On the basis of these tests, we used the parametric
approach for our data analysis. The mean waiting, service, and
idling times were calculated. Patients’ satisfaction was analyzed
using frequencies. Box plots were used to compare waiting
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times between men and women according to type of patient. A
difference in means plot was also used to visually inspect and
compare the means between categorical variables including
gender, age group, arrivals, diagnosis, and residence.
Association of Waiting Time and Satisfaction
Logistic regression [45] with reported odds ratios (ORs) was
performed to establish the existence of any association between
waiting time and patient satisfaction. Participants’ satisfaction
was modeled with waiting time, age, and gender using the
logistic regression, and ORs with 95% CIs were calculated.
Effectiveness of PDSA
Independent sample 2-tailed t test [46] was used to compare the
waiting time and satisfaction of the preintervention and
postintervention groups. Box plots and pie charts were used to
visually examine the pre-post intervention effects on waiting
time and patient satisfaction, respectively, according to gender
and type of patient.
Ethics Approval
Consistent with the Helsinki Declaration of 1975, the protocol
for this study was developed and approved by the ethics
committee of the London School of Hygiene and Tropical
Medicine (15444). Ethics approval was also obtained from the
institutional review board of MICEI (0003/L/DG/DM/PA/KBG).
All the participants provided written informed consent. All the
data forms submitted to the server were encrypted using a pair
of public keys. Participants received reimbursement for their
consultation fees.
Results
The study findings are reported in accordance with the revised
Standards for Quality Improvement Reporting Excellence
(version 2.0) guidelines [47].
Participant Demographics
A total of 49 participants, 15 (31%) of whom were reviews,
participated in the study. Their mean age was 49 (SD 15.7)
years, ranging from 19 to 80 years (25/49, 51% were women).
Participants were recruited into two consecutive samples
(preintervention sample and postintervention sample) and
matched for age and self-reported sex. The mean age for the
preintervention arm (25/49, 51% of the participants; 13/25, 52%
were women) was 49.3 (SD 14.6) years and that for the
postintervention arm (24/49, 49% of the participants; 12/24,
50% were women) was 49.6 (SD 17) years. Most patients
(38/49, 78%) arrived between 6 and 9 AM for their consultation.
Table 1 presents the sociodemographic characteristics of the
study participants.
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Table 1. Sociodemographic characteristics (N=49).

Characteristics Preintervention participants (n=25), n (%) Postintervention participants (n=24), n (%)
Age (years)
15-24 1 (4) 3 (13)
25-54 14 (56) 10 (42)
55-64 5 (20) 7 (29)
65-80 5 (20) 4 (17)

Gendera
Men 12 (48) 12 (50)
Women 13 (52) 12 (50)
Patient type
New 18 (72) 16 (67)
Review 7 (28) 8 (33)
Marital status
Married and cohabiting 17 (68) 14 (58)
Single 6 (24) 7 (29)
Divorced and widow 2 (8) 3 (13)
Residence
Littoral 0 (0) 2 (8)
Far North 1 (4) 1 (4)
Center 20 (80) 20 (83)
West 2 (8) 0 (0)
Northwest 0 (0) 1 (4)
South 1 (4) 0 (0)
Origin
Littoral 0 (0) 1 (4)
Center 14 (56) 8 (33)
West 9 (36) 14 (58)
Northwest 1 (4) 0 (0)
North 0 (0) 1 (4)
South 1 (4) 0 (0)
Work status
Formal 9 (36) 6 (25)
Informal 8 (32) 13 (54)
Others 8 (32) 5 (21)
Education
None 1 (4) 1 (4)
Elementary 3 (12) 1 (4)
b 6 (24) 11 (46)
GCE —ordinary level
GCE—advance level 3 (12) 2 (8)
University 4 (16) 7 (29)
Doctorate 8 (32) 2 (8)
Travel time

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Characteristics Preintervention participants (n=25), n (%) Postintervention participants (n=24), n (%)

<1 hour 18 (72) 19 (79)
A few hours 5 (20) 4 (17)
Half a day 1 (4) 0 (0)
1-2 days 1 (4) 1 (4)
Transport means
Private 6 (24) 6 (25)
Public 18 (72) 18 (75)
Motorbike 1 (4) 0 (0)
Arrival time
5-7 AM 14 (56) 5 (21)
7-9 AM 7 (28) 14 (58)
9-11 AM 4 (16) 5 (21)

a
Self-reported.
b
GCE: General Certificate of Education.

by an ophthalmic nurse with the help of a slit lamp before seeing

Patient Pathway (Patient Flow)
The patient flow chart starts at the gate where patients are
handed a number upon arrival. Medical record files are initiated
at the reception by calling the patients based on numbers.
Patients are also advised on the consultation fee based on the
consultation option chosen (very important person, fast track,
or standard). Patients are registered in the medical records upon
presentation of a cash receipt of the consultation fee. If patients
are on a repeat visit, their medical record file will have to be
retrieved by the medical records officer to proceed to the next
service point. In the general ophthalmology unit, visual acuity,
blood pressure, and intraocular pressure are measured by
assistant ophthalmic nurses. The visual acuity determines
whether patients should be refracted. Patients are prescreened
the general ophthalmologist. The general (outpatient)
ophthalmologist may request for mydriatic eye drops to be
instilled if necessary. Then, he refers patients to subspecialty
units based on the anterior and posterior chamber assessments
(using a slit lamp). The flow is such that there may be
back-and-forth movements owing to counterreferrals. At the
end of the intervention, 96% (47/49) of the participants had
visited the general ophthalmology department. Altogether, 49%
(24/49) of the participants had visited the cataract and glaucoma
unit and 31% (15/49) had visited the cornea and refractive errors
unit. There was no marked difference in service point visits
according to gender and sample. Figure 2 shows the patient
flow at the clinic.

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Figure 2. Authors’ conception—patient pathway protocol.
Intervention Time Line
In the preintervention phase, 51% (25/49) of the participants
participated in a time-motion and satisfaction survey. On the
basis of the interim analysis, changes were implemented. The
second group of 49% (24/49) participants was recruited for the
time-motion survey after the changes, and the 2 groups were
compared.
The first 7 changes were implemented, which includes the
following: (1) a time monitor sheet to record the start and finish
times at each service point, (2) introduction of a second
receptionist for the separate handling of review patients, (3)
expansion of the numbering system to include all patients, (4)
patient flow supervision for on-the-spot handling of bottlenecks,
(5) triaging of patient files led by assistant nurses at the general
ophthalmology department, (6) proactive sorting of patient files
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in the medical records, and (7) regular patient education by a
medical record staff. These changes were implemented
simultaneously as a package.
Of the 10 originally proposed changes, three changes (ie,
standardization of waiting time by defining the duration for a
full consultation, granting ophthalmic nurses the permission to
discharge less complicated cases, and color zoning of the general
ophthalmology department) could not be implemented owing
to cost and time constraints. For instance, color zoning of the
outpatient waiting area required a formal contract award
procedure. Other three measures, including the phasic
appointment system, effective triaging, and patient education,
could not be fully implemented owing to staff shortage, lack of
qualified nurses, and lack of audiovisual materials, respectively.
Figure 3 displays the waiting time series with the intervention
effect.
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Figure 3. Time line of time-motion and satisfaction survey.
Waiting Time and Patient Satisfaction
At baseline, the mean waiting time (service time and idle time)
for a comprehensive eye examination at the MICEI was found
to be 450 (SD 96.6) minutes. The mean service time was 112
(SD 47) minutes and the mean idling time was 338 (SD 98.1)
minutes. The idle time (338 minutes) spent by patients was 3
times more than that being served. The service points with high
mean waiting times at baseline included room 15 with 204 (SD
86.1) minutes, room 20 with 203 (SD 141.4) minutes, room 13
with 185 (SD 46.1) minutes, room 18 with 161 (SD 63.5)
minutes, and room 16 with 99 (SD 97.4) minutes. At baseline,
the highest proportion of idling time was among patients going
through room 15 (196 minutes/204 minutes, 96%), room 20
(192 minutes/203 minutes, 95%), room 13 (167 minutes/185
Figure 4. Baseline waiting time of new and review patients by gender.
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minutes, 90%), room 18 (140 minutes/161 minutes, 87%), and
room 16 (84 minutes/99 minutes, 85%).
The mean waiting time for men was 472 (SD 86.5) minutes and
that for women was 429 (SD 104.1) minutes. Men spent 77%
(362 minutes/472 minutes) of the time in idling, whereas women
spent 73% (315 minutes/429 minutes) of the time. Table S1 in
Multimedia Appendix 3 shows the detailed waiting, service,
and idling times by service point and gender.
The mean waiting time for new patients was 485 (SD 67)
minutes and that for reviews was 359 (SD 105.8) minutes. Both
new patients and reviews spent 75% of the waiting time in idling
(364 minutes/485 minutes and 269 minutes/359 minutes,
respectively). Figure 4 shows the baseline waiting, service, and
idling times of new and review patients by gender.
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Of the 51% (25/49) of the participants who participated in the
baseline survey, 32% (8/25) reported that they were satisfied
with the waiting time, 63% (5/8) of whom were women and
75% (6/8) were new patients. Among the participants who
reported to be dissatisfied (17/25, 68%), 76% (13/17)
complained of long waiting time as the main reason for
dissatisfaction, whereas 24% (4/17) complained of queue
jumping.
At baseline, 28% (7/25) of the participants in the preintervention
sample was reviews. All 7 participants reported that they were
dissatisfied with their first visit to the clinic. Of these
participants, 43% (3/7) agreed that they were satisfied with the
current visit.
Association of Waiting Time and Satisfaction
We performed binary outcome logistic regression because
satisfaction was a binary outcome. Waiting time was not a good
predictor of satisfaction, as the negative association (z=−0.9)
was not statistically significant (OR 1, 95% CI 0.99-1; P=.37;
χ23=0.4). Further investigation by gender and age group did not
show any significant difference.
Effectiveness of PDSA
An independent sample t test showed that the mean waiting
time reduction from 450 (95% CI 409.7-489.5) minutes at
baseline to 384 (95% CI 327.8-440.6) minutes after intervention
was not statistically significant, with 15% (66 minutes/450
minutes) reduction in mean waiting time (t47=2; P=.05). The
mean service time significantly reduced from 112 (95% CI
92.5-131.3) minutes to 85 (95% CI 71.9-98) minutes (t47=2.4;
P=.02), whereas the mean idling time reduced from 338 (95%
CI 297.2-378.2) minutes to 299 (95% CI 248.3-350.3) minutes.
The reduction in waiting time was mainly driven by high service
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rate, as the difference of 38 (95% CI −24.7 to 101.5) minutes
in idling time was not statistically significant (t47=1.2; P=.20).
Tables S1 and S2 in Multimedia Appendix 3 show the effects
of the intervention on waiting and service times. The mean
waiting time for women increased by 2% (10 minutes/429
minutes), whereas that for men reduced by 30% (142
minutes/472 minutes). Service time for men was 1.6 times (33
minutes/20 minutes) more likely to reduce than that for women.
In addition, the idling time for men was similar before (362
minutes/472 minutes, 77%) and after the intervention (253
minutes/330 minutes, 77%), whereas that for women increased
from 73% (315 minutes/429 minutes) to 79% (345 minutes/438
minutes). A detailed distribution of waiting time is provided in
Table S1 in Multimedia Appendix 3.
The mean waiting time for new patients reduced by 11% (53
minutes/485 minutes) and that for reviews reduced by 20% (71
minutes/359 minutes). The intervention was approximately
twice as likely to have a positive impact on the waiting time of
reviews. Figure 5 shows the intervention’s effect on waiting
time.
Figure 6 shows an overview of the intervention’s effect on the
distribution of waiting time and satisfaction.
The satisfaction with waiting time increased slightly from 32%
(8/25) at baseline to 33% (8/24) after the intervention. This
difference (0.01, 95% CI −0.2 to 0.3) was not statistically
significant (z=0.1; P=.9). The percentage of new patients who
reported to be satisfied increased from 33% (6/18) to 38%
(6/16), whereas that for reviews decreased from 29% (2/7) to
25% (2/8). In addition, those who said that they were satisfied
tended to be older than those who did not. Figure 7 shows the
satisfaction with waiting time by gender.
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Figure 5. Intervention effect on waiting time.

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Figure 6. Comparison of preintervention and postintervention waiting time.

Figure 7. Pre-post comparison of patient satisfaction.

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Unintended Outcomes
The intervention led to unexpected increase in the waiting time
for the general ophthalmologist examination. In addition, the
intervention appeared to have affected women adversely, as
evidenced by the slight increase reported in the waiting time.
A mean comparison across variables showed that this effect
Figure 8. Difference in means by category.
Discussion
Principal Findings
We found mean waiting time of 450 (SD 96.6) minutes, mean
service time of 112 (SD 47) minutes, and mean idling time of
338 (SD 98.1) minutes. The PDSA intervention led to 15% (66
minutes/450 minutes) improvement in mean waiting time (t47=2;
P=.05), from 450 (95% CI 409.7-489.5) minutes at baseline to
384 (95% CI 327.8-440.6) minutes after the intervention. Only
one-third of the participants reported being satisfied with the
waiting time (8/25, 32%) at baseline. Waiting time was not
found to be associated with satisfaction (OR 1, 95% CI 0.99-1;
P=.37; χ23=0.4).
Comparison With Previous Studies
Baseline Waiting Time
Other studies have reported high mean clinic waiting times;
however, we have not found any reports as high as our finding.
Mean waiting time of 274 (SD 103.4) minutes was reported
among adults visiting the University of Port Harcourt Teaching
Hospital in Nigeria, which was lower than the 450 (SD 96.6)
minutes we found in this study [48]. The sample size (n=401)
was much larger than ours, and the medical services and patient
flow involved significantly few steps for the patient to navigate.
The short patient pathway may explain the short time spent at
the clinic. The mean waiting time of 104.1 (SD 96.4) minutes
found in a study conducted at the Thong Nhat Hospital in
Vietnam was also lower than our finding [49]. In that study,
patients saw the consultant immediately after registering, and
the consultant either recommends a blood or imaging test. The
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was more marked for women in the age group of 15 to 24 years
(Figure 8).
Further investigation showed that the 6% (3/49) of women who
belonged to the age group of 15 to 24 years were enrolled after
the intervention, thus giving a wrong indication of an adverse
effect.
patient revisits the physician and, then, is sent to the pharmacy.
This pathway with 5 service points and rapid access to the senior
physician can explain the lower waiting time compared with
our study, where patients had to visit 12 service points on
average. Another study conducted in a teaching hospital in
Nigeria reported 160.2 (SD 62.4) minutes of waiting time [50].
In that study, waiting time was defined as the time from
registration to seeing the physician, rather than the total visit
time that we used in our study. Similarly, a study at the
Kintampo Municipal Hospital in Ghana reported a mean total
visit time of 303.6 (SD 94.8) minutes (5.06 hours) [51]. Their
patient pathway comprised only 6 service points. A pilot quality
improvement using PDSA cycles in an operating theater unit
of a tertiary hospital in India found the average waiting time at
baseline to be 221 minutes [42]. Differences in waiting time
measurement can explain the low waiting time, which was
limited to time at the operating theater. Similarly, at the
Medunsa Oral Clinic in South Africa, the mean total time spent
at the clinic among 149 patients was reported to be 235.79 (SD
78.79) minutes, which is approximately 2 times lower than the
450 (SD 96.6) minutes reported in our study [52]. The patient
pathway for the dental clinic was simple with only five service
points (check-in, reception, diagnostic room, treatment, and
checkout). Another study at the Jos University Teaching
Hospital in Nigeria showed that the total mean outpatient time
was 248 minutes [53]. Again, patients in this study followed a
simple patient pathway, being sent to see the physician after
registration, after which they were sent to the pharmacy. A
waiting time audit among 316 women attending an antenatal
clinic in Ghana showed that the mean time spent at the clinic
was 6.5 hours, which is close to the 7.5 hours reported in our
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study [54]. Although the definition of waiting time in their study
was similar to that used in ours, the 6.5 hours waiting time in
their study was based on the reported time spent at the clinic
rather than a time audit, as was the case in our study. As such,
no details about the patient pathway were given, but 73% of the
participants (n=204) noted that most of the time was spent in
waiting to see the physician.
From these findings, it appears that streamlining the patient
pathway by reducing the number of service points that the
patients have to navigate and giving the patient access to the
physician faster may be a good strategy to reduce overall waiting
times.
Service and Idling Times
In our study, the proportion of idling time increased from 75%
(338 minutes/450 minutes) to 78% (299 minutes/384 minutes)
after the intervention, even though there was a general reduction
in mean waiting time.
Similar studies in other settings also reported high idling times,
such as a study in China, among 49 outpatients in an
endocrinology center, that reported the idling time to be 89%
(150.5 minutes/168.3 minutes) [10]. A multicenter study across
9 clinics in KwaZulu-Natal (South Africa) with a sample size
of 1763 (baseline: n=860 and follow-up: n=903) used a health
service strengthening framework over 12 months and reported
the proportion of idling time after the intervention to be 94%
(115 minutes/122 minutes) [55]. Akinyinka et al [56] found the
eye clinic service time at a primary care center in Lagos to be
8.2 (SD 2) minutes, similar to our findings of 8.5 (SD 8.8)
minutes for the general ophthalmologist in our study. In
Southwestern Ethiopia, a study including 853 patients showed
that patients spent a total time of 553.4 minutes in going through
all service points, of which 50% (274.9 minutes/553.4 minutes)
was spent in waiting for services [57]. At the University of
Benin Teaching Hospital in Nigeria, the proportion of time spent
before seeing the physician was reported to be 85% (22
minutes/146 minutes) [58].
In New York, patients spent 58% (53 minutes/91.9 minutes) of
the mean total visit time in waiting to be called into a room
(20.1 minutes), for the provider (18.6 minutes), and for the
preceptor (14.3 minutes) [59]. Visit time was based on
appointment visits, with a much simple patient pathway
including only registration and examination room. A study
including 555 patients attending a teaching clinic in Sacramento
(the United States) reported the time spent at the clinic to be
80.5 (SD 30) minutes, of which 19 (SD 16) minutes were spent
idling [60]. Their waiting time was based on an individual
appointment system and involved a 2-stage consultation
(registration and examination room). Our study was based on
a block appointment system with multiple provider service
points. A study in a pediatric clinic in the United States reported
the idling time to be 20.9 to 23.9 minutes for consultations and
15.8 to 20.32 minutes for the filling of prescriptions, using a
Lean Six Sigma model [61]. Their idling times were not
computed for the entire patient pathway, as these were the times
patients waited before being attended to after registration and
the time between paying the prescription bill and being called
at the pharmacy, respectively.
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This evidence suggests that patients attending clinics in
low-income and middle-income settings, in particular, may be
spending most of their time in waiting to receive a service,
referred to as idling waiting time in our study. It would be
pertinent to consider interventions that focus specifically on
decreasing the time patients spend between service points and
possibly reducing the number of service points in the patients’
pathway. Our intervention decreased the overall waiting time,
but likely through a proportionally large reduction in service
time rather than idling time. The length of consultation may
affect patient safety and clinical effectiveness, and caution
should be exercised when introducing measures that reduce the
time of consultations, which are already brief [62-66].
Reduction in Waiting Time
Our study reports a reduction of 15% in waiting time through
the intervention, which is less than the original target of 25%
reduction. This can be a result of not being able to implement
all the originally planned components of the intervention and
the short time between intervention implementation and analysis.
In addition, the involvement of physicians in training on the
last day of our study led to an unusually high waiting time of
702 minutes for the last participant, thereby affecting our mean
results.
Several studies of interventions to reduce waiting times report
reductions in the same range as that reported in our study.
Racine et al [59] conducted a before-after study, including 844
patients (group 1=426; group 2=418) at a pediatric clinic in the
East Bronx in New York and reported a reduction of 15% (13.6
minutes/91.9 minutes) in mean total visit time. The reduction
in mean waiting time achieved in our study was also comparable
with the 13% (28 minutes/208 minutes) reported in a before-after
study using the Lean Six Sigma model, with the National Heart
Institute in Cairo, Egypt, over 16 months [67]. In the United
States, Ciulla et al [68] achieved 18% reduction through their
intervention, using the Lean Six Sigma model. Another study
conducted in an emergency department in Singapore over 6
months showed 12% reduction using a similar model [69].
Improvements at the Fujiang Provincial Hospital in China [8]
reduced the mean waiting time per month for consultations by
34% (8.1 minutes/23.9 minutes). In addition, 2 public primary
care centers in South Africa reported reductions of 21% (27
minutes/129 minutes) and 29% (79 minutes/275 minutes),
respectively, in waiting time [70]. This study was also
implemented in 3 phases over 8 months, which can explain the
higher reduction compared with our study.
In general, we found that our reduction rate falls within the
range reported in other published studies using similar
methodologies. A long implementation time and the opportunity
to incorporate all the components of the intervention could have
improved our results.
Association Between Patient Satisfaction and Waiting
Time
In this study, we found little evidence of association between
waiting time and patient satisfaction (OR 1, 95% CI 0.99-1.00;
P=.37). Another study from China, with a similarly small sample
size (49 patients), also reported nonsignificant negative
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association between time spent at the clinic and satisfaction
(r=−0.07) [10].
A study at the Hamilton Regional Eye Institute in Canada
reported significant association between waiting time and patient
satisfaction (OR 0.92, 95% CI 0.86-0.98; P=.01) [71]. The study
was based on an appointment system and implemented over 8
months, which is more likely to be a sufficient period to explore
this relationship. A comparative study between primary care
centers in Gauteng and Free State in South Africa found a
negative association between patients’ impression about time
spent at the clinic and satisfaction [72]. Strong negative
association between patient satisfaction and waiting time was
also reported among 1403 antenatal care visits in Kenya and
859 in Namibia, across 564 and 303 health facilities, respectively
[73]. Negative association was also observed among 1617
patients with HIV, undergoing antiretroviral therapy in Nigeria
[74]. In Malawi, negative association between waiting time and
patient satisfaction was reported among 120 women undergoing
cervical cancer screening, as was the case among 406
participants seeking laboratory services at antiretroviral therapy
clinics in Addis Ababa in Ethiopia [75,76].
We report that patients who were dissatisfied commonly
complained of long waiting times (13/17, 76%). Other studies
from Canada, India, and Cameroon reported similar findings
(79%, 73.3%, and 73%, respectively) [77-79].
The decrease in waiting time achieved through our intervention
was not reflected in a significant improvement in patient
satisfaction after the intervention. We believe that the effect
size was not sufficiently large to affect patient satisfaction over
a short time at the clinic, and it is possible that a large significant
impact on waiting time reduction and a large sample size are
needed for it to be a good predictor of patient satisfaction.
Strengths and Limitations
This is the first quality improvement study in Cameroon with
the primary end point of improving waiting time, using a mobile
data collection kit for real-time patient monitoring. In addition
to providing some evidence in circumstances under which
randomized controlled trials may not be possible [80], this study
prioritizes and places users at the forefront of quality
improvement [81]. The data collection method was automated,
thereby reducing data entry errors.
Being the first quality improvement intervention, the change
process was slower than expected. The limited influence over
contextual factors could have affected the intervention’s degree
of success. In addition, not all changes that were proposed were
implemented, which also limited the impact of the intervention.
The sample size was limited by the data collection method.
Each data collector could follow up only a single patient at a
time from start to finish. This limited the daily enrollment to a
maximum of 2 patients per data collector and sometimes just a
single participant, depending on the consultation cycle. A large
sample size would have led to a more normally distributed
outcome variable and better inference. Finally, we did not
perform subgroup analysis of the changes implemented, to
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measure the impact of each change on waiting time and
satisfaction.
The unexpected increase in the waiting time for the general
ophthalmologist examination may have been caused by a fast
service rate of the preceding units, indicating the importance of
considering the patient pathway in its entirety when designing
interventions. It was also found that women experienced slight
increase in their waiting time. Investigating the reasons for this
finding is beyond the scope of this study and would require
further exploration in a study with a large sample size.
Public Health Implications
This study sets the pace for further considerations regarding the
delivery of evidence-based patient-centered eye care [82]. There
is an urgent need to rethink the eye care delivery strategy in
Cameroon [18,83]. The postpandemic era will need even more
efficient health systems. This will require patients to be
considered as partners in quality improvement. Our intervention
is a demonstration of how relatively small investments can lead
to service improvements. Further studies are needed to improve
waiting time and reduce the opportunity cost of consultation
for patients.
Conclusions
We sought to improve waiting time and patients’ satisfaction
using PDSA-led quality improvement. We found 15% borderline
significant improvement in waiting time over 6 weeks,
suggesting that PDSA-led quality improvement at MICEI is
promising over a long period. Our results suggest that improving
the waiting time in the short run will not produce significant
improvements in patient satisfaction in the setting under study.
This study highlights the importance of patient-centered quality
improvement, which helps to improve the provider-user
relationship. Given the lack of evidence on the acceptable
waiting time for a comprehensive eye examination at MICEI,
our results provide a benchmark for standardizing the cycle time
for a comprehensive eye examination.
We recommend that strategies aimed to reduce waiting time
focus on reducing the idling time rather than affecting the
consultation time. These may include reducing the number of
service points that the patient has to navigate in the clinic and
considering placing the consultation with the physician earlier
in the patient flow. In addition, introduce a phasic appointment
system, starting with reviews and progressively introducing
them to new patients. Specific measures introduced with this
intervention should be incorporated routinely in the clinic, such
as the following: (1) automated patient flow monitoring system
that tracks the start and finish times at each service point, (2)
introduction of a second receptionist for the separate handling
of reviews, (3) implementation of robust ticketing at the gate
and reception for all patients, (4) queue length checks along the
patient pathway and waiting time threshold alert system for
on-the-spot handling of bottlenecks, (5) triaging of patient files
led by assistant nurses at the general ophthalmology department,
(6) proactive sorting of patient files in the medical records, and
(7) use of audiovisual materials for patient education on the
patient pathway and waiting time.
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Acknowledgments
The authors thank the Open Data Kit (Get ODK Inc) team at the London School of Hygiene and Tropical Medicine for assisting
with the server, Romulo Fabunan for coordinating the funding, Dr Ted Afetane, and the quality improvement team members.
The authors also extend their gratitude to the Magrabi International Council of Ophthalmology Cameroon Eye Institute management
and staff for their support. This study was funded by the Queen Elizabeth Diamond Jubilee Trust through the Commonwealth
Eye Health Consortium (MbwoggeMathew-201718). MM was affiliated with the International Center for Eye Health at the time
of the study and is currently an independent researcher.

Data Availability
The data set for this study will be made available upon reasonable request. Kindly contact the corresponding author with detailed
study protocol and justification of funding to conduct the study.

Authors' Contributions
MM designed the study and intervention and led the participant recruitment, data analysis, and development of the manuscript.
C Bascaran contributed to developing the intervention and manuscript preparation. NA provided guidance for study development.
HEN contributed to the institutional review board approval and quality improvement team setup. C Bunce advised on the analysis
and reviewed the statistics in the manuscript. All authors read and approved the manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Evaluation of contextual factors.
[DOCX File , 14 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Survey questionnaire.
[PDF File (Adobe PDF File), 713 KB-Multimedia Appendix 2]

Multimedia Appendix 3
Distribution of waiting time.
[DOCX File , 25 KB-Multimedia Appendix 3]

References
1. Kern C, König A, Fu DJ, Schworm B, Wolf A, Priglinger S, et al. Big data simulations for capacity improvement in a
general ophthalmology clinic. Graefes Arch Clin Exp Ophthalmol 2021 May;259(5):1289-1296 [FREE Full text] [doi:
10.1007/s00417-020-05040-9] [Medline: 33386963]
2. Abidova A, da Silva PA, Moreira S. The mediating role of patient satisfaction and perceived quality of healthcare in the
emergency department. Medicine (Baltimore) 2021 Mar 19;100(11):e25133 [FREE Full text] [doi:
10.1097/MD.0000000000025133] [Medline: 33725994]
3. Abidova A, da Silva PA, Moreira S. Predictors of patient satisfaction and the perceived quality of healthcare in an emergency
department in Portugal. West J Emerg Med 2020 Jan 27;21(2):391-403 [FREE Full text] [doi: 10.5811/westjem.2019.9.44667]
[Medline: 31999247]
4. Bruce C, Harrison P, Giammattei C, Desai SN, Sol JR, Jones S, et al. Evaluating patient-centered mobile health technologies:
definitions, methodologies, and outcomes. JMIR Mhealth Uhealth 2020 Nov 11;8(11):e17577 [FREE Full text] [doi:
10.2196/17577] [Medline: 33174846]
5. Jabour AM. The impact of electronic health records on the duration of patients’ visits: time and motion study. JMIR Med
Inform 2020 Feb 07;8(2):e16502 [FREE Full text] [doi: 10.2196/16502] [Medline: 32031539]
6. Vahdat V, Griffin J, Stahl JE. Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory
care clinics. Health Care Manag Sci 2018 Dec;21(4):492-516. [doi: 10.1007/s10729-017-9407-5] [Medline: 28795264]
7. Sommer AC, Blumenthal EZ. Implementation of Lean and Six Sigma principles in ophthalmology for improving quality
of care and patient flow. Surv Ophthalmol 2019;64(5):720-728. [doi: 10.1016/j.survophthal.2019.03.007] [Medline:
30951728]

https://med.jmirx.org/2022/3/e34263 JMIRx Med 2022 | vol. 3 | iss. 3 | e34263 | p. 16

(page number not for citation purposes)
XSL• FO
RenderX
 JMIRx Med Mbwogge et al

8. Sun J, Lin Q, Zhao P, Zhang Q, Xu K, Chen H, et al. Reducing waiting time and raising outpatient satisfaction in a Chinese
public tertiary general hospital-an interrupted time series study. BMC Public Health 2017 Aug 22;17(1):668 [FREE Full
text] [doi: 10.1186/s12889-017-4667-z] [Medline: 28830400]
9. Lin WC, Goldstein IH, Hribar MR, Sanders DS, Chiang MF. Predicting wait times in pediatric ophthalmology outpatient
clinic using machine learning. AMIA Annu Symp Proc 2020 Mar 4;2019:1121-1128 [FREE Full text] [Medline: 32308909]
10. Xie Z, Or C. Associations between waiting times, service times, and patient satisfaction in an endocrinology outpatient
department: a time study and questionnaire survey. Inquiry 2017;54:46958017739527 [FREE Full text] [doi:
10.1177/0046958017739527] [Medline: 29161947]
11. Framework for Improving Quality in Our Health Service. Health Service Executive. 2016. URL: https://www.hse.ie/eng/
about/who/qid/nationalsafetyprogrammes/decontamination/quality-improvement-framework.pdf [accessed 2021-04-22]
12. Lin CK. An adaptive scheduling heuristic with memory for the block appointment system of an outpatient specialty clinic.
Int J Prod Res 2015 Sep 23;53(24):7488-7516. [doi: 10.1080/00207543.2015.1084060]
13. Romano MR, Montericcio A, Montalbano C, Raimondi R, Allegrini D, Ricciardelli G, et al. Facing COVID-19 in
ophthalmology department. Curr Eye Res 2020 Jun;45(6):653-658. [doi: 10.1080/02713683.2020.1752737] [Medline:
32253942]
14. Mbwogge M. Mass testing with contact tracing compared to test and trace for the effective suppression of COVID-19 in
the United Kingdom: systematic review. JMIRx Med 2021 Apr 12;2(2):e27254 [FREE Full text] [doi: 10.2196/27254]
[Medline: 33857269]
15. Munavalli JR, Rao SV, Srinivasan A, Srinivas A, van Merode F. The optimization in workflow management: ophthalmology.
J Health Manag 2016 Mar 15;18(1):21-30. [doi: 10.1177/0972063415625570]
16. GBD 2019 Blindness and Vision Impairment Collaborators, Vision Loss Expert Group of the Global Burden of Disease
Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness
in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. Lancet Glob Health
2021 Feb;9(2):e144-e160 [FREE Full text] [doi: 10.1016/S2214-109X(20)30489-7] [Medline: 33275949]
17. Dean WH, Buchan JC, Gichuhi S, Faal H, Mpyet C, Resnikoff S, et al. Ophthalmology training in sub-Saharan Africa: a
scoping review. Eye (Lond) 2021 Apr;35(4):1066-1083 [FREE Full text] [doi: 10.1038/s41433-020-01335-7] [Medline:
33323984]
18. Bechange S, Jolley E, Virendrakumar B, Pente V, Milgate J, Schmidt E. Strengths and weaknesses of eye care services in
sub-Saharan Africa: a meta-synthesis of eye health system assessments. BMC Health Serv Res 2020 May 06;20(1):381
[FREE Full text] [doi: 10.1186/s12913-020-05279-2] [Medline: 32375761]
19. McIntyre D, Chow CK. Waiting time as an indicator for health services under strain: a narrative review. Inquiry
2020;57:46958020910305 [FREE Full text] [doi: 10.1177/0046958020910305] [Medline: 32349581]
20. Atnafu A, Haile Mariam D, Wong R, Awoke T, Wondimeneh Y. Improving adult ART clinic patient waiting time by
implementing an appointment system at Gondar University Teaching Hospital, Northwest Ethiopia. Adv Public Health
2015 Sep 14;2015:1-5 [FREE Full text] [doi: 10.1155/2015/892464]
21. Caffery LJ, Farjian M, Smith AC. Telehealth interventions for reducing waiting lists and waiting times for specialist
outpatient services: a scoping review. J Telemed Telecare 2016 Dec;22(8):504-512. [doi: 10.1177/1357633X16670495]
[Medline: 27686648]
22. Eno LT, Asong T, Ngale E, Mangwa B, Ndasi J, Mouladje M, et al. Driving hospital transformation with SLMTA in a
regional hospital in Cameroon. Afr J Lab Med 2014 Nov 3;3(2):221 [FREE Full text] [doi: 10.4102/ajlm.v3i2.221] [Medline:
29043192]
23. Njong AM, Tchouapi RP. Assessing User Satisfaction with the Quality of Healthcare Services in Cameroon. African
Economic Research Consortium. 2020 Jul. URL: https://aercafrica.org/wp-content/uploads/2020/09/Aloysius-Rosy-672.
pdf [accessed 2021-04-23]
24. Ajeh R, Ekane H, Thomas EO, Dzudie A, Jules AN. Perceived patients’ satisfaction, barriers and implications on engagement
in antiretroviral treatment services in Cameroon within the HIV Test and Treat context. Am J Public Health Res 2019 May
23;7(2):73-80 [FREE Full text]
25. Dougherty G, Abena T, Abesselo JP, Banda JN, Biyaga TP, Boccanera R, et al. Improving services for HIV-exposed infants
in Zambia and Cameroon using a quality improvement collaborative approach. Glob Health Sci Pract 2021 Jun
30;9(2):399-411 [FREE Full text] [doi: 10.9745/GHSP-D-20-00550] [Medline: 34234027]
26. Bediang G, Stoll B, Elia N, Abena JL, Geissbuhler A. SMS reminders to improve adherence and cure of tuberculosis patients
in Cameroon (TB-SMS Cameroon): a randomised controlled trial. BMC Public Health 2018 May 02;18(1):583 [FREE Full
text] [doi: 10.1186/s12889-018-5502-x] [Medline: 29720146]
27. Moen RD, Norman CL. Circling Back: Clearing up myths about the Deming cycle and seeing how it keeps evolving. Quality
Progress. 2010 Nov. URL: http://www.apiweb.org/circling-back.pdf [accessed 2022-03-26]
28. Ambroggio L, Schondelmeyer A, Hoefgen E, Brady P, Shaughnessy E. Quality improvement feature series article 4:
advanced designs for quality improvement studies. J Pediatric Infect Dis Soc 2018 Dec 03;7(4):335-337. [doi:
10.1093/jpids/pix082] [Medline: 29045666]

https://med.jmirx.org/2022/3/e34263 JMIRx Med 2022 | vol. 3 | iss. 3 | e34263 | p. 17

(page number not for citation purposes)
XSL• FO
RenderX
 JMIRx Med Mbwogge et al

29. Mormer E, Stevans J. Clinical quality improvement and quality improvement research. Perspect ASHA SIGs 2019 Feb
26;4(1):27-37 [FREE Full text] [doi: 10.1044/2018_pers-st-2018-0003]
30. Knudsen SV, Laursen HV, Johnsen SP, Bartels PD, Ehlers LH, Mainz J. Can quality improvement improve the quality of
care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Serv
Res 2019 Oct 04;19(1):683 [FREE Full text] [doi: 10.1186/s12913-019-4482-6] [Medline: 31585540]
31. Ma J, Wong BM, Micieli JA, Calafati J, Low S, El-Defrawy S, et al. Vision to improve: quality improvement in
ophthalmology. Can J Ophthalmol 2020 Apr;55(2):107-115. [doi: 10.1016/j.jcjo.2019.07.020] [Medline: 31712012]
32. Rosencrans LC, Sume GE, Kouontchou JC, Voorman A, Anokwa Y, Fezeu M, et al. Mapping for health in Cameroon:
polio legacy and beyond. J Infect Dis 2017 Jul 01;216(suppl_1):S337-S342 [FREE Full text] [doi: 10.1093/infdis/jix008]
[Medline: 28838181]
33. El-Maghraby A, elMaghraby A, Alireza M, Etya'ale DE, Felch WC, Makary T, et al. Magrabi ICO Cameroon Eye Institute,
Yaoundé, Cameroon: ophthalmology subspecialty patient care and training center in Central Africa. Am J Ophthalmol
2019 Jan;197:98-104 [FREE Full text] [doi: 10.1016/j.ajo.2018.09.010] [Medline: 30240727]
34. Coles E, Wells M, Maxwell M, Harris FM, Anderson J, Gray NM, et al. The influence of contextual factors on healthcare
quality improvement initiatives: what works, for whom and in what setting? Protocol for a realist review. Syst Rev 2017
Aug 23;6(1):168 [FREE Full text] [doi: 10.1186/s13643-017-0566-8] [Medline: 28830572]
35. Kringos DS, Sunol R, Wagner C, Mannion R, Michel P, Klazinga NS, DUQuE Consortium. The influence of context on
the effectiveness of hospital quality improvement strategies: a review of systematic reviews. BMC Health Serv Res 2015
Jul 22;15:277 [FREE Full text] [doi: 10.1186/s12913-015-0906-0] [Medline: 26199147]
36. The Model for Understanding Success in Quality (MUSIQ). East London NHS Foundation Trust. URL: https://qi.elft.nhs.uk/
resource/the-model-for-understanding-success-in-quality-2/ [accessed 2021-04-22]
37. Quality, Service Improvement and Redesign Tools: Plan, Do, Study, Act (PDSA) Cycles and the Model for Improvement.
NHS England and NHS Improvement. URL: https://www.england.nhs.uk/wp-content/uploads/2022/01/
qsir-pdsa-cycles-model-for-improvement.pdf [accessed 2021-04-25]
38. Elfil M, Negida A. Sampling methods in clinical research; an educational review. Emerg (Tehran) 2017;5(1):e52 [FREE
Full text] [Medline: 28286859]
39. Maduka O, Akpan G, Maleghemi S. Using Android and open data kit technology in data management for research in
resource-limited settings in the Niger delta region of Nigeria: cross-sectional household survey. JMIR Mhealth Uhealth
2017 Nov 30;5(11):e171 [FREE Full text] [doi: 10.2196/mhealth.7827] [Medline: 29191798]
40. Fereday S, Malbon N. A Guide to Quality Improvement Methods. Healthcare Quality Improvement Partnership. 2015.
URL: https://www.hqip.org.uk/wp-content/uploads/2018/02/guide-to-quality-improvement-methods.pdf [accessed
2022-03-21]
41. Plourde CL, Varnado WT, Gleaton BJ, Das DG. Reducing infusion clinic wait times using quality improvement. JCO Oncol
Pract 2020 Aug;16(8):e807-e813. [doi: 10.1200/JOP.19.00643] [Medline: 32142391]
42. Chandra P, Tewari R, Dolma Y, Das D, Kumawat D. Reducing preoperative waiting-time in a pediatric eye operation
theater by optimizing process flow: a pilot quality improvement project. Indian Pediatr 2018 Sep 15;55(9):773-775 [FREE
Full text] [Medline: 30345983]
43. Altema J, Bien-Aime K, Roger MC, Blaise W. Causes of long wait time in health consultation services and strategies to
reduce them: an observational study in rural Haiti. Lancet Glob Health 2020 Apr 1;8:S33. [doi:
10.1016/s2214-109x(20)30174-1]
44. Mishra P, Pandey CM, Singh U, Gupta A, Sahu C, Keshri A. Descriptive statistics and normality tests for statistical data.
Ann Card Anaesth 2019;22(1):67-72 [FREE Full text] [doi: 10.4103/aca.ACA_157_18] [Medline: 30648682]
45. Ranganathan P, Pramesh CS, Aggarwal R. Common pitfalls in statistical analysis: logistic regression. Perspect Clin Res
2017;8(3):148-151 [FREE Full text] [Medline: 28828311]
46. Hopkins S, Dettori JR, Chapman JR. Parametric and nonparametric tests in spine research: why do they matter? Global
Spine J 2018 Sep;8(6):652-654 [FREE Full text] [doi: 10.1177/2192568218782679] [Medline: 30202720]
47. Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement
Reporting Excellence): revised publication guidelines from a detailed consensus process. Am J Med Qual 2015;30(6):543-549
[FREE Full text] [doi: 10.1177/1062860615605176] [Medline: 26497490]
48. Ogaji D, Mezie-Okoye M. Waiting time and patient satisfaction: survey of patients seeking care at the general outpatient
clinic of the University of Port Harcourt Teaching Hospital. Port Harcourt Med J 2017 Nov 29;11(3):148-155 [FREE Full
text] [doi: 10.4103/phmj.phmj_41_17]
49. Thi Thao Nguyen S, Yamamoto E, Thi Ngoc Nguyen M, Bao Le H, Kariya T, Saw YM, et al. Waiting time in the outpatient
clinic at a national hospital in Vietnam. Nagoya J Med Sci 2018 May;80(2):227-239 [FREE Full text] [doi:
10.18999/nagjms.80.2.227] [Medline: 29915440]
50. Omotoye OJ, Ajayi IA, Ajite KO, Ajogbasile OO. Factors responsible for prolong waiting time of patients seeking eye care
at a tertiary health facility. Asian Pac J Health Sci 2017 Jun 30;4(2):224-228 [FREE Full text] [doi:
10.21276/apjhs.2017.4.2.35]

https://med.jmirx.org/2022/3/e34263 JMIRx Med 2022 | vol. 3 | iss. 3 | e34263 | p. 18

(page number not for citation purposes)
XSL• FO
RenderX
 JMIRx Med Mbwogge et al

51. Dixon CA, Punguyire D, Mahabee-Gittens M, Ho M, Lindsell CJ. Patient flow analysis in resource-limited settings: a
practical tutorial and case study. Glob Health Sci Pract 2015 Mar;3(1):126-134 [FREE Full text] [doi:
10.9745/GHSP-D-14-00121] [Medline: 25745126]
52. Motloba P, Ncube O, Makwakwa L, Machete M. Patient waiting time and satisfaction at a Tertiary Dental School. South
Afr Dent J 2018 Jul;73(6):p400-p405 [FREE Full text] [doi: 10.17159/2519-0105/2018/v73no6a3]
53. Thacher TD. Outpatient waiting time in Jos University Teaching Hospital. Highl Med Res J 2005 Oct 12;3(1):36-42. [doi:
10.4314/hmrj.v3i1.33865]
54. Donkor ES, Obed SA. Waiting time and women's satisfaction at an antenatal clinic in Ghana. Afr J Midwifery Womens
Health 2012 Jan;6(1):7-12. [doi: 10.12968/ajmw.2012.6.1.7]
55. Egbujie BA, Grimwood A, Mothibi-Wabafor EC, Fatti G, Tshabalala AM, Allie S, et al. Impact of 'Ideal Clinic'
implementation on patient waiting time in primary healthcare clinics in KwaZulu-Natal Province, South Africa: a
before-and-after evaluation. S Afr Med J 2018 Mar 28;108(4):311-318 [FREE Full text] [doi:
10.7196/SAMJ.2017.v108i4.12583] [Medline: 29629682]
56. Akinyinka MR, Adebayo BI, Wright KO, Adeniran A. Client waiting time in an urban primary health care centre in Lagos.
J Community Med Prim Heal Care 2016 Jul 13;28(1):17-24 [FREE Full text]
57. Addissie A, Jira C, Bekele F. Patient waiting and service time in the outpatient department of Jimma Hospital. Ethiop J
Health Sci 1998 Jan;8(1):15-21 [FREE Full text]
58. Enabulele O, Ajokpaniovo J, Enabulele JE. Patient waiting and consultation time in the general practice clinic of the
University of Benin teaching hospital, Edo State, Nigeria. J Fam Med Commun Health 2018 Mar 23;5(2):1146 [FREE Full
text]
59. Racine AD, Davidson AG. Use of a time-flow study to improve patient waiting times at an inner-city academic pediatric
practice. Arch Pediatr Adolesc Med 2002 Dec;156(12):1203-1209. [doi: 10.1001/archpedi.156.12.1203] [Medline: 12444831]
60. Xakellis Jr GC, Bennett A. Improving clinic efficiency of a family medicine teaching clinic. Fam Med 2001;33(7):533-538.
[Medline: 11456246]
61. Jayasinha Y. Decreasing turnaround time and increasing patient satisfaction in a safety net hospital-based pediatrics clinic
using lean six sigma methodologies. Qual Manag Health Care 2016;25(1):38-43. [doi: 10.1097/QMH.0000000000000083]
[Medline: 26783866]
62. Hu G, Liu L, Chen Y, Liu Y. Association between consultation length and patient experience of ambulatory care in China:
a cross-sectional study. Lancet 2018 Oct 1;392:S68. [doi: 10.1016/s0140-6736(18)32697-7]
63. Wilson A, Childs S. The relationship between consultation length, process and outcomes in general practice: a systematic
review. Br J Gen Pract 2002 Dec;52(485):1012-1020 [FREE Full text] [Medline: 12528590]
64. Elmore N, Burt J, Abel G, Maratos FA, Montague J, Campbell J, et al. Investigating the relationship between consultation
length and patient experience: a cross-sectional study in primary care. Br J Gen Pract 2016 Dec;66(653):e896-e903 [FREE
Full text] [doi: 10.3399/bjgp16X687733] [Medline: 27777231]
65. Lemon TI, Smith RH. Consultation content not consultation length improves patient satisfaction. J Family Med Prim Care
2014;3(4):333-339 [FREE Full text] [doi: 10.4103/2249-4863.148102] [Medline: 25657939]
66. Cape J. Consultation length, patient-estimated consultation length, and satisfaction with the consultation. Br J Gen Pract
2002 Dec;52(485):1004-1006 [FREE Full text] [Medline: 12528588]
67. Wong R, Hathi S, Linnander EL, El Banna A, El Maraghi M, El Din RZ, et al. Building hospital management capacity to
improve patient flow for cardiac catheterization at a cardiovascular hospital in Egypt. Jt Comm J Qual Patient Saf 2012
Apr;38(4):147-153 [FREE Full text] [doi: 10.1016/s1553-7250(12)38019-7] [Medline: 22533126]
68. Ciulla TA, Tatikonda MV, ElMaraghi YA, Hussain RM, Hill AL, Clary JM, et al. Lean six sigma techniques to improve
ophthalmology clinic efficiency. Retina 2018 Sep;38(9):1688-1698. [doi: 10.1097/IAE.0000000000001761] [Medline:
28723845]
69. Shen Y, Lee LH. Improving the wait time to consultation at the emergency department. BMJ Open Qual 2018 Jan
3;7(1):e000131 [FREE Full text] [doi: 10.1136/bmjoq-2017-000131] [Medline: 29333496]
70. Sastry A, Long KN, de Sa A, Salie H, Topp S, Sanghvi S, et al. Collaborative action research to reduce persistently long
patient wait times in two public clinics in Western Cape, South Africa. Lancet Glob Health 2015 Mar;3:S18. [doi:
10.1016/s2214-109x(15)70137-3]
71. Chan BJ, Barbosa J, Moinul P, Sivachandran N, Donaldson L, Zhao L, et al. Patient satisfaction with wait times at an
emergency ophthalmology on-call service. Can J Ophthalmol 2018 Apr;53(2):110-116. [doi: 10.1016/j.jcjo.2017.08.002]
[Medline: 29631820]
72. Nunu WN, Munyewende PO. Patient satisfaction with nurse-delivery primary health care services in Free State and Gauteng
provinces, South Africa: a comparative study. Afr J Prim Health Care Fam Med 2017 Apr 28;9(1):e1-e8 [FREE Full text]
[doi: 10.4102/phcfm.v9i1.1262] [Medline: 28470074]
73. Do M, Wang W, Hembling J, Ametepi P. Quality of antenatal care and client satisfaction in Kenya and Namibia. Int J Qual
Health Care 2017 Apr 01;29(2):183-193. [doi: 10.1093/intqhc/mzx001] [Medline: 28453821]

https://med.jmirx.org/2022/3/e34263 JMIRx Med 2022 | vol. 3 | iss. 3 | e34263 | p. 19

(page number not for citation purposes)
XSL• FO
RenderX
 JMIRx Med Mbwogge et al

74. Agu KA, Oqua D, Agada P, Ohiaeri SI, Adesina A, Abdulkareem MH, et al. Assessment of satisfaction with pharmaceutical
services in patients receiving antiretroviral therapy in outpatient HIV treatment setting. Int J Clin Pharm 2014
Jun;36(3):636-647. [doi: 10.1007/s11096-014-9948-3] [Medline: 24736896]
75. Maseko FC, Chirwa ML, Muula AS. Client satisfaction with cervical cancer screening in Malawi. BMC Health Serv Res
2014 Sep 22;14:420 [FREE Full text] [doi: 10.1186/1472-6963-14-420] [Medline: 25245860]
76. Mindaye T, Taye B. Patients satisfaction with laboratory services at antiretroviral therapy clinics in public hospitals, Addis
Ababa, Ethiopia. BMC Res Notes 2012 Jul 04;5:184 [FREE Full text] [doi: 10.1186/1756-0500-5-184] [Medline: 22520145]
77. Fraser J, Atkinson P, Gedmintas A, Howlett M, McCloskey R, French J. A comparative study of patient characteristics,
opinions, and outcomes, for patients who leave the emergency department before medical assessment. CJEM 2017
Sep;19(5):347-354. [doi: 10.1017/cem.2016.375] [Medline: 27692013]
78. Sundresh NJ, Nagmothe RV. A study of determinant of long waiting period in outpatient department and recommendation
on reducing waiting time in a superspecialty hospital. J Med Sci Clin Res 2017 Dec 07;5(12):208-213 [FREE Full text]
[doi: 10.18535/jmscr/v5i12.43]
79. Fouogue JT, Tchounzou R, Fouelifack FY, Fouedjio JH, Dohbit JS, Sando Z, et al. Evaluation of patients' satisfaction after
laparoscopic surgery in a tertiary hospital in Cameroon (Africa). Pan Afr Med J 2017 Nov 8;28:216 [FREE Full text] [doi:
10.11604/pamj.2017.28.216.11441] [Medline: 29629002]
80. de Vocht F, Katikireddi SV, McQuire C, Tilling K, Hickman M, Craig P. Conceptualising natural and quasi experiments
in public health. BMC Med Res Methodol 2021 Feb 11;21(1):32 [FREE Full text] [doi: 10.1186/s12874-021-01224-x]
[Medline: 33573595]
81. The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. Nursing and Midwifery Council.
2015 Jan 29. URL: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf [accessed
2021-05-19]
82. Alkureishi MA, Lee WW, Webb S, Arora V. Integrating patient-centered electronic health record communication training
into resident onboarding: Curriculum development and post-implementation survey among housestaff. JMIR Med Educ
2018 Jan 04;4(1):e1 [FREE Full text] [doi: 10.2196/mededu.8976] [Medline: 29301735]
83. Dorcas W, Emilliene E, Estella TF, Joseph EA, Kovin N, Jaggernath J, et al. An overview of herbal traditional eye care
practices and the development of eye health promotion strategies in Cameroon. J Adv Med Pharm Sci 2019 Jun 21;20(4):1-16.
[doi: 10.9734/jamps/2019/v20i430118]

Abbreviations
MICEI: Magrabi International Council of Ophthalmology Cameroon Eye Institute
ODK: Open Data Kit
OR: odds ratio
PDSA: Plan-Do-Study-Act

Edited by E Meinert; submitted 13.10.21; peer-reviewed by A Argyriadis, H Ayatollahi, Anonymous; comments to author 06.03.22;
revised version received 04.04.22; accepted 09.06.22; published 09.08.22
Please cite as:
Mbwogge M, Astbury N, Nkumbe HE, Bunce C, Bascaran C
Waiting Time and Patient Satisfaction in a Subspecialty Eye Hospital Using a Mobile Data Collection Kit: Pre-Post Quality Improvement
Intervention
JMIRx Med 2022;3(3):e34263
URL: https://med.jmirx.org/2022/3/e34263
doi: 10.2196/34263
PMID:

©Mathew Mbwogge, Nicholas Astbury, Henry Ebong Nkumbe, Catey Bunce, Covadonga Bascaran. Originally published in
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